A Purple Public Health: The individual and the public

This piece was co-written by Dr Salma Abdalla and is also cross-posted here.

Public health is concerned with health at the population level. Most of the time our work as public health scientists and practitioners, expands rather than restricts what people can do with their lives. Clean water, safe food, and the countless quieter interventions that constitute public health have given people more years, more options, and more freedom to live the lives they wish to live. But sometimes, the pursuit of public health requires that individuals accept constraints on their choices for the sake of the population’s health.

There is nothing particularly new about this restricting feature of public health. But this feature was brought to the fore in an unprecedently visible way during the Covid-19 pandemic. Vaccine mandates, mask requirements, and restrictions on movement and gathering all surfaced a national conversation about the role of public health: when is it right for the field to infringe on an individual’s autonomy in the name of the population’s health, and when is it not? The debate has not settled since. If anything, it has widened, as the field faces questions about harm reduction, policies to tackle obesity, and many other issues where the line between protecting populations and respecting individuals is less clear than we sometimes think.

This month, we want to take the question of where autonomy sits when we develop public health policies seriously. By autonomy, we mean the ability to govern oneself, to make one’s own choices, and to act according to one’s own reasons rather than external coercion. We recognize that autonomy claims are more complicated in particular cases, including for example where children, acute crisis, or compromised capacity are involved. But for what follows, we have in mind the ordinary case: an adult going about their life, making choices about what to eat, what to buy, where to live, how to move through the world.

When we argue about autonomy and freedom, we are often not actually disagreeing about the same thing. Some of us might be talking about freedom understood as the absence of interference, such as the freedom to choose what to eat, what to drink, what risks to take with one’s own body. Some of us may be talking about freedom understood as the conditions under which meaningful choice is possible. This includes the freedom from disease, from injury, from the circumstances that make healthy choices hard or impossible to sustain. Both freedoms matter. Yet public debates routinely collapse them into a single contest in which one must win and the other must lose. This is familiar terrain in the liberal tradition; the philosopher Isaiah Berlin distinguished between freedom from external interference and the freedom to pursue what one has reason to value and argued that both are important in a free society.

We have written before about how this tension appears in public health, using the more accessible language of freedom “to” and freedom “from.” Many of the rights we celebrate most in the American tradition are rights to do something, including the right to speak, vote, assemble, etc. Much of the work of public health, by contrast, is about freedom from something: freedom from preventable illness, from unsafe food, from the environmental and economic conditions that shorten lives. Neither kind of freedom is more important than the other. Neither is more American than the other. But because one has tended to dominate our national conversation, the work of public health has sometimes appeared to be operating against the grain of freedom, when in fact it is often operating in service of a version of freedom that is simply less often named. And we think it is worth remembering that this is not only a progressive position. Edmund Burke described liberty as “secured by the equality of restraint.” Burke’s point is that institutions and rules are not the enemies of liberty; they are what make liberty possible for everyone rather than for only the strongest.

Consider the Bloomberg-era New York City effort to limit the size of sugary drinks offered in restaurants and other venues. The policy was widely described as a question of whether the city could tell people what size soda they were allowed to buy. Framed this way, the answer was obvious to most voters: of course not. Yet framed differently—as a question about whether a person should be free from a food environment engineered, at every turn, to encourage overconsumption of products known to cause chronic disease—the debate might have looked quite different. The same pattern has played out across other public health interventions. The debate over indoor smoking bans was, for decades, framed as a question about the freedom to smoke in the places one chose to smoke, rather than as a question about the freedom from breathing other people’s smoke while trying to eat, work, or travel.

All of this is to say that the freedom-to/freedom-from reframing is an important insight, rooted in a long liberal tradition, and public health has every right to claim it. But we would caution against letting the reframing do too much work on our behalf. Not every public health intervention is clearly an exercise in freedom from something. The harder cases are where the rest of this essay turns.

The starting point, we think, is that the strength of public health’s claim on an individual’s autonomy depends heavily on the directness of the harm at stake to the population. A person carrying a highly contagious and dangerous disease, Ebola is an example often invoked, poses a direct and identifiable risk to others and will be quarantined. In such cases, public health has both the authority and the obligation to act, and the field has long developed standards for when that threshold is reached. Such measures are reserved for circumstances in which the evidence of transmissibility and severity is strong, the intervention is proportionate, and the alternatives are inadequate. When the field does conclude that intervention is justified, it is obliged to choose the version of that intervention that achieves its aim with the least intrusion on individual liberty. This is not a new idea. It has been articulated in various forms in public health ethics for decades, under headings like the least restrictive means or the ladder of intervention. But it has not always been applied with the discipline it deserves. When a mandate will do, a mandate is chosen. When a ban will do, a ban is enacted. Less restrictive alternatives such as incentives and structural changes to the choice environment sometimes receive less attention than they should, particularly when the field is under pressure to demonstrate decisive action.

The case becomes more difficult when the harm is largely to the individual themselves. Here, the argument that autonomy must yield becomes much harder to sustain, and the field’s authority to act becomes much more contested. It is tempting, in these cases, to reach for arguments about indirect harms to others such as the costs borne by the healthcare system or the drag on economic productivity. While these arguments are not wrong, they are not the same as direct harm and treating them as though they were risks extending public health’s authority into territory where it does not belong. A society that accepts the premise that any individual choice with downstream costs to others justifies public health intervention has accepted a premise that leaves very little of private life untouched.

The hardest cases, thus, are the ones where the science supports the intervention, the intent is good, and yet the intervention still asks something of individual autonomy that may be difficult to justify on public health grounds alone. There are cases where the science alone that cannot provide a single correct answer and where societal values should play a role. Before turning to these cases, is one observation worth making upfront. Public health interventions that restrict individual choice in the name of health tend to fall, disproportionately, on people with less economic and political power. We do not think this makes such interventions categorically wrong. But we do think it imposes a heightened obligation on the field to be especially careful, especially transparent, and especially honest about what we are asking of people who already have fewer choices than most.

With that in mind, three case examples.

Motorcycle helmet laws. The evidence shows that helmets reduce the risk of fatal head injury substantially, and universal helmet laws increase helmet use to near-universal levels in the states that have them. This is a clear public health gain. However, a rider who is wearing a helmet poses essentially no additional risk to anyone else; the risk being managed is largely to the rider themselves, which makes this also an autonomy question. The harm to others arguments, such as costs to emergency rooms, are sometimes invoked to justify these laws. At the same time, we rarely advocate for universal helmet laws for anyone in a moving car despite the potential benefits. Reasonable people largely agree that the helmet law is the right call for a motorcycle but not for a car. But that would be an argument about tradeoffs, not autonomy. Making a harm to others argument to justify a motorcycle mandate, if accepted as sufficient, would justify intervention in nearly any risky activity an adult might choose and would create a public health that is heavily paternalistic.

Smoking restrictions in public housing. Banning smoking in public housing units is a policy that has expanded in recent years and that has a public health rationale. Where secondhand smoke moves through shared ventilation, the harm-to-others argument applies, and the field’s authority rests on familiar ground. But the policy is sometimes defended, and applied, even where the secondhand exposure risk is minimal. If the harm is almost entirely to the smoker themselves, the question is whether public health has the authority to restrict an adult’s behavior in their own home for their own good. This is, by most accounts, a question about paternalism. A restriction that would be politically unthinkable if applied to homeowners is applied, here, to people whose housing depends on accepting it. This is not itself a reason to abandon the policy, but it is a reason to hold it to a higher standard of justification than we sometimes have.

Restrictions on what food assistance can buy. The question of whether food assistance benefits should be usable for sugary drinks, snack foods, or other products associated with poor dietary outcomes is among the most politically scrambled in contemporary public health. It is supported by some on the right, who see it as a reasonable condition on public spending, and by some on the left, who see it as a way of improving nutrition among low-income populations. We think the strongest argument in its favor is that the government has a legitimate interest in the health outcomes of the programs it funds. We also think the strongest argument against it is that a restriction of this kind, applied only to people using food assistance, singles out low-income Americans for a form of supervision that no one else is asked to accept. If the concern is really about the health effects of these products, the more consistent response would be to tax them broadly, or to regulate their marketing, or to restrict their sale in ways that apply to everyone. The case to restrict food benefits may still be defensible. But it deserves to be defended on its actual merits, rather than under cover of a generalized claim on improving nutrition policy in the US.

Autonomy should be one of the goods public health exists to protect as much as possible. When we forget this, we do harm to the people we serve and to the field itself. A purple public health does not pretend the tension between autonomy and the population can be resolved once and for all. It takes the tension as a permanent feature of the field’s work and asks us to engage with it honestly rather than to paper it over. Much of the time, we are not asking anything of individuals that they would not, on reflection, choose for themselves. When we are asking something of individuals, we should be honest that we are asking, and we should be disciplined about how much we ask. Most importantly, we should be particularly careful, and particularly transparent, when the interventions we reach for fall hardest on those with the fewest resources and the least political power to push back.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Justin Bernstein, Assistant Professor in the Department of Philosophy at the University of Virginia. Justin and Salma examine when, if ever, public health can justify limiting individual autonomy in the interest of population health. The conversation works through different ways of understanding freedom and several recent debates — Covid-19 lockdowns, vaccine mandates, soda taxes, food assistance restrictions, and smoking bans in public housing — and asks whether public health risks imposing its own view of the “good life” when it prioritizes health above other values people may hold.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

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Also this week

In Journal of Clinical Psychiatry:

A Longitudinal Analysis of Self-Rated Health Correlates and Predictors in Hurricane Survivors – with Jeffrey Pavlacic, Jesse Walker, Arthur Andrews III, and Kenneth Ruggiero

In this episode of Ideas Matter, I spoke with Stanford Medicine’s John Ioannidis about the replication crisis and the future of science.